HWN Suggests

Practical Tips On Diaphragm Injury

Diaphragm injuries are notoriously hard to detect, and there is a significant rate of delayed or missed diagnosis...

Mechanism is important. Penetrating injury is more common, and it can be really tough to diagnose this injury in stabs to the lower chest. Anything below the nipples is suspect. Blunt injury requires substantial force. This is seen in deceleration injuries, usually with a crush component to the abdomen. Ejection and partial ejection is common.

Left sided injury is much more common than right. The liver probably diffuses the force more evenly, protecting the right diaphragm. Be very skeptical if a radiologist tries to tell you the patient has a right diaphragm…

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 Diaphragm injury

More common in penetrating trauma. Suspect also in severe blunt trauma (e.g. abdominal crush injury, ejection)

 Spontaneous Diaphragmatic Hernia

A patient presenting to the emergency department (ED) in respiratory distress with unilateral breath sounds does not have an extensive differential diagnosis. In a trauma scenario a pneumothorax or hemothorax quickly comes to mind. It is taught that a chest tube should be inserted without further diagnostic testing. In the non-traumatic patient a spontaneous pneumothorax, pleural effusion, pneumonia, or airway foreign body are among the most likely etiologies. Spontaneous diaphragmatic hernia (SDH) is not often considered, and thus may be a missed diagnosis during initial evaluation.

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A Fiendish Finding

A 21 year-old female presents with acute onset of unrelenting abdominal pain and vomiting four years after a major motor vehicle accident. A chest X-ray is performed:

Diaphragmatic rupture

It is frequently not recognized at the time of trauma and the interval between injury and the onset of symptoms. However, if the diagnosis is not made in the first 4 hours, it may be undiagnosed for months or years. The left hemidiaphragm is involved three times more frequently than the right, possibly because the liver has a buffering effect. The most common site of rupture is the posterolateral aspect of the hemidiaphragm between the lumbar and intercostal muscle slips. Ruptures occur radially and most are >10 cm in length. The most commonly herniated viscera are the stomach and colon. It is rare to see rupture of the diaphragm without evidence of abdominal trauma, although this may be seen in the context of iatrogenic injury.

Dramatic Diaphragmatic Hernia

In case you didn’t encounter shortness of breath today!

What’s Wrong In This Photo? The Answer

The obvious diagnosis is an easy one! An NG tube is seen curled in the stomach, which is located above the diaphragm! This patient has a traumatic rupture of the left diaphragm. The other, slightly less obvious finding is a spleen injury. Wait, this is a plain chest x-ray

Resources

Teach Me Surgery

For adult patients, whilst initial diagnosis may be suspected on CXR, often CT imaging of the chest is performed (Fig. 3), as this is especially useful for pre-operative planning.